Pandemics do not start in a vacuum. A staggering 2.3 billion infections by zoonotic (animal-borne) pathogens afflict people in developing countries every year. Some pathogens become capable of easy human-to-human spread, like AIDS, flu, or severe acute respiratory syndrome (SARS). The diseases harm health, nutrition, and food and income security. The poorest are hit the worst, as they tend to live with livestock or near wild animals in settings where animal disease incidence is high and public health standards are low.

This zoonotic disease burden persists because of weak veterinary and human public health systems that fail to detect diseases and allow them to spread. The onset of pandemics is thus shaped by human action. Any country’s failure to stop contagion early at its animal source can cause a pandemic in today’s globalized economy, which is interconnected by trade and travel.

A severe flu pandemic would more than double the total burden of disease, but other impacts would be even more costly. Economies would suffer from worker absenteeism, cascading disruptions in goods and service markets, and human reactions to fear and rumors, which can spread faster than the disease itself. Recently declassified U.S. government planning documents characterize the impact as a global war. Poor countries, especially fragile ones, may be least able to cope.

What does it take to prevent a pandemic? The main cause of pandemic risk is low capacity of veterinary and human public health systems. Bringing them up to meet minimum international standards requires only modest resources: $3.4 billion a year for all developing countries, compared with the current level of barely $450 million. The expected annual benefits of robust systems are at least $37 billion, more than 10 times the costs.

Pandemic risk is undermanaged. Prevention and preparedness tend to be sidelined, especially in the health sector, where the responsibility often rests. Health authorities focus on immediate problems and do not readily work with veterinary authorities to prevent diseases of tomorrow or coordinate society-wide preparedness and plans for continuity of operations in key sectors.

Why such neglect? The economic and social impacts of contagion are often ignored, so the total risk is underestimated. Recent experience shows how wide this gap can be. The 2003 SARS outbreak, which killed about 10% of the 8,000 people it infected, caused $54 billion in economic damage (mostly canceled travel, lost retail trade, and associated cross-border economic shocks). A severe flu pandemic could cost 4.8% of global gross domestic product (GDP), or more than $3 trillion, triggering a global recession. Recall that four flu pandemics occurred just in the last 100 years, and other pathogens with pandemic potential continue to emerge, so in any year the probability of pandemic onset is not zero.

The international community has not yet expressed its demand for pandemic risk reduction by adopting explicit goals but instead resorts to emergency responses that are costly and contain the threat only temporarily. Because risk governance is not backed by resources and authority, numerous weak links persist in global defenses against contagion. To stop contagion, it is essential to act early, at the source, and quickly. Early warning requires cooperation from communities. If farmers who report disease are punished by having their livestock destroyed without compensation, they will hide disease from the authorities. Fearing trade and travel restrictions, countries may hide diseases, facilitating their spread.

Governments with resources try to protect their own populations by spending large amounts on ex-post measures (e.g., vaccines, masks, and antivirals), although prevention at the source of the threat has much higher benefit-cost ratios. In particular, the promising One Health approach to reducing disease risks through bridges between animal and human health services is underfunded and too often dismissed by human health policymakers. This is surprising since 75% of pathogens that cause human disease are now zoonotic, and the burden of zoonotic diseases on the poor is a formidable obstacle to eliminating poverty and boosting shared prosperity.

The international community has already eradicated two devastating scourges: smallpox in 1979, and rinderpest (cattle plague) in 2011. Rinderpest, with its high fatality rate, decimated herds and economies for centuries. The campaign against it catalyzed the founding of the World Organisation for Animal Health (OIE) in 1924.

Intergovernmental cooperation, science-based strategies, mass vaccination, and surveillance were among the elements behind these successful campaigns. The disease risk was reduced to zero. The benefits are lasting and already outweigh the control costs many times over. Coordination among strong public health agencies broke the chain of transmission of SARS. Faced with the H5N1 avian flu threat, the international community rapidly mobilized and deployed $4 billion for zoonotic disease control and pandemic preparedness. This impressive multisectoral response to a global public health emergency focused on prevention, but it dissipated when the threat left the headlines.

The young and future generations face far worse odds of experiencing a pandemic than present-day adults. They stand to benefit substantially if governments were to set a goal to reduce pandemic risk. The goal would empower international organizations to raise risk awareness and motivate prevention and preparedness; provide relevant knowledge, capacity building, and technical assistance to developing countries; assess the performance of national veterinary and human public health systems and their collaboration; and mobilize resources for strengthening these systems.

Comments

Thank you for this fascinating blog. Has the World Bank done any research on the reason why the needed public health investment has not already happened? Investing $3.4 billion in order to earn $37 billion. It seems like a no-brainer to me!!! But I am not a banker. :) seriously, what is the reason?

If we do not invest in this public health and One health, then the bottom 6 billion - the world's poor -- will suffer many premature deaths and illness.The rich will always survive so they could for that reason be less concerned about preventing a pandemic.

The World Bank could invest this money itself, and make an enormous profit?

Thank you for the thanks and the comments. The reasons for lack of investment in public health, though the returns are highly attractive, are complex. Poor governance and lack of government accountability are probably the most important ones. And I agree that the poor in developing countries would be disproportionately hard-hit by pandemic impact.

The cost-benefit ratio of bringing the human and animal public health systems is incredibly high when compared to the vast majority of alternative investments in just about anything. The writer has done us a real service by summarizing arguably the most important part of WDR 2014. It would be foolish if the these findings are not followed through. To keep the focus on the crucial importance of public health services, one of the goals of the next batch of MDGs should include the goal of reducing pandemic risks.

I agree with you. The benetit-cost ratio is so high for several reasons, including: (1) there are weak links in the system, so the "last-mile" investments in public health capacities have extraordinarily high returns; (2) cooperation between veterinary and human public health systems is inadequate, so investment in this weak link also has high returns; (3) contagion spreads exponentially so there is a huge benefit to early action to contain it; and (4) there is now much scientific knowledge about contagion (how to detect and diagnose and contain) and how it spreads but this knowledge has not yet informed policy making and allocation of resources. As for the post-MDG goals, the background paper has some ideas about the kind of goals that could make sense. Goals are useful if they translate into incentives for the various actors to work together and start to close the dangerous gaps in defenses against pathogens.

The title says it all: Diseases Without Borders. This is a global public good, just like reducing carbon emissions. The payoff to organized action is huge (as is the cost of inaction).

It's good to see the World Bank take a lead on this issue, since it can't be left to private markets. The World Bank is the perfect agency for doing this, given its multisectoral mandate and global reach.

These issues have been ignored in favor of more attention-grabbing health interventions with much lower payoff for health outcomes.

Developed countries made these low-cost public health investments with high long-term payoffs. It is in their interest to ensure this is done across the world, to avoid the costs of pandemics to their own lives and economies.

Dear Monica, thank you for the comment. It's puzzling that reduction of pandemic risk is not "attention grabbing." Perhaps a better analogy than with investments in health services that can tangibly improve lives today, is to consider defense against contagion as national defense, which enjoys strong political and popular backing over time, with stable funding. On the other hand, the huge economic, societal, and health benefits of pandemic prevention are there and in principle should be sufficient to justify the modest investments...

Occurrence of Pandemics points poor or ineffective global public health practices as outbreaks turning into epidemics are indicative of local ineffective or poor public health practice. As several diseases donot have borders golbal investment in strengthening public health practices is a must. Life is precious. It cannot be measured through economic loss alone. Prevention of epidemics needs large investment from private/public sector for newer diagnostic tools and vaccines. Some profit throgh manufacture or use of those is immaterial.World bank itself should not engage. World Bank should support strengthening of public health system and not get involved in profit making buisness.

Thank you for you comment. If the international community were to decide that pandemic risk should be reduced, then the main role for the Bank would be in supporting the investments in veterinary and human public health systems, to bring them up to WHO and OIE performance standards, and contributing to coordination at global, regional, and country levels. There is also a potential Bank role in promoting multisectoral, whole-of-society preparedness to respond. Neither of these groups of activities would be profitable to the Bank, but they would generate substantial benefits for all Bank members.

Thanks for sharing, a very to the point publication. After working on the crossroad between human health and animal health, mainly in China for the past 10 years, I see no other option than a common approach in prevention and control of emerging animal diseases, especially in Asia. What I also experienced is the lack of interest of the emerging animal protein producers in participating in such an approach. After all, the producers carry large costs in case of large-scale outbreaks.
If raising awareness and increasing biosecurity would be rewarded by making it possible to insure the direct and indirect financial losses, preparedness planning, risk education and early detection would become an economic value in itself, like it is when you take a fire insurance as an example. As long as preparation is done on the basis of National guidelines, followed poor implementation and control because of the costs, bio security at farm level remains undervalued.

Pandemics in the past had killed millions. It comtinues to kill thousands but what is important now is the global economic loss affecting trade and travel. Revised IHR is in place, Whether same will prevent or reduce pandemics only future will tell because still in many countries effective public health infrastructure is not in place to deliver IHR efficiently.Bank is currently supporting Disesae specific control/elimination/eradication activities in many countries. For effective delivery of these activities at the country level instead of supporting disease specific infrastructure alone focus needs to be on overall public health infrastructure throgh an effectibe public health policy involving all thge relevant sectors and opening up one window for public health delivery.